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Anterior composite restorations: A systematicreview on long-term survival and reasons forfailure

ARTICLE in DENTAL MATERIALS: OFFICIAL PUBLICATION OF THE ACADEMY OF DENTAL MATERIALS · AUGUST 2015Impact Factor: 3.77 · DOI: 10.1016/j.dental.2015.07.005

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Flavio Fernando Demarco

Universidade Federal de Pelotas

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Marcos Britto Correa


77 PUBLICATIONS 433 CITATIONS

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Maximiliano Cenci



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Niek J M Opdam

Radboud University Nijmegen


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Please cite this article in press as: Demarco FF, et al. Anterior composite restorations: A systematic review on long-term survival and reasonsfor failure. Dent Mater (2015), http://dx.doi.org/10.1016/j.dental.2015.07.005

ARTICLE IN PRESSDENTAL-2596; No.of Pages 11

d en ta l m at er ia ls x x x ( 2 0 1 5 ) xxx–xxx

Available

online

at

www.sciencedirect.com

ScienceDirect

j o u rn a l h om epag e : ww w. in t l . e l s ev i e rhea l t h . com/ jou rna l s / dema

Review

Anterior composite restorations: A systematicreview on long-term survival and reasons forfailure

Flávio F. Demarco a , ∗ , Kauê Collares a , Fabio H. Coelho-de-Souza b,

Marcos

B. Correaa

, Maximiliano S. Cencia

, Rafael R. Moraesa

,Niek J.M. Opdam ca Graduate Program in Dentistry, School of Dentistry, Federal University of Pelotas, Pelotas, RS, Brazilb School of Dentistry, Federal University of Rio Grande do Sul, Porto Alegre, RS, Brazilc Department of Restorative and Preventive Dentistry, Radboud University Nijmegen Medical Centre, Nijmegen,The Netherlands

a r t i c l e i n f o

Article history:Received 31 March 2015Received in revised form12 June 2015Accepted 29 July 2015Available online xxx

Keywords:Anterior teethBuild-upsClinical trialsComposite resinsLongevitySurvivalVeneers

a b s t r a c t

Objective. In this study the literature was systematically reviewed to investigate the clinicallongevity of anterior composite restorations.Data. Clinical studies investigating the survival of anterior light-cured composite restora-tions with at least three yearsof follow-up were screened andmain reasons associated withrestoration failure were registered.Sources. PubMed,Scopus, andCochranedatabases were searchedwithout restriction on dateor language. Referencelistsofeligiblestudieswere hand-searched.Thegrey literaturesearchwas not made systematically.Studyselection. Tworeviewers screenedtitles and/or abstracts of 2273unique studies. In total,41 studies were selected for full-text reading, from which 17 were included in the qualita-tive synthesis. Theincludedstudies evaluated theclinicalperformanceof Class III and/or IVrestorations (10 studies), which were placed due to caries, fracture, or replaced old restora-tions; veneers and full-coverage restorations placed for aesthetic reasons (ve studies); andrestorationsin worn teeth (two studies).Annual failure rates (AFRs)werecalculated foreachstudy.Conclusions. In total, 1821 restorations were evaluated and the total failure rate was 24.1%.AFRs variedfrom0 to 4.1% andsurvival ratesvaried from 53.4%to 100%.Class IIIrestorationsgenerally had lower AFRs than the other restorations. Few studies addressed factors asso-ciated with failure, which included adhesive technique, composite resin, retreatment risk,

∗ Corresponding author at : Graduate Program in Dentistry, Federal University of Pelotas Rua Gonçalves Chaves 457, Room 506 96015-560,Pelotas-RS, Brazil. Tel.: +55 53 3222 6690x135; fax: +55 53 3222 6690x135.

E-mail addresses: [email protected] , [email protected] (F.F. Demarco).http://dx.doi.org/10.1016/j.dental.2015.07.005

0109-5641/© 2015 Academy of Dental Materials. Published by Elsevier Ltd. All rights reserved.

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ARTICLE IN PRESSDENTAL-2596; No.of Pages 11d en ta l m a te ri a ls x x x ( 2 0 1 5 ) xxx–xxx 3

cavities, direct veneers, and full-coverage build-ups. Includedstudies should have a follow-up time of at least three years.

2.2. Search strategy

Selection of studies was based on a search strategy foreach international electronic database (National Library of Medicine – MEDLINE/PubMed, SciVerse Scopus, and CochraneCentral Register of Controlled Trials), being the last search car-ried out in December 3, 2014. The structured search strategyis detailed in Table 1. The search and selection of studies wasperformed without any restriction on date or language. Thereferences of all eligible studies identied by the search werechecked to nd other relevantstudies,whilethe grey literaturesearch was not made systematically.

2.3. Study selection

Titles and abstracts of all identied studies were screenedindependently by two reviewers (K.C. and F.H.C.) for eligibility.All studies that met the eligibility criteria were selected forfull-text reading. Full-text articles that fullled the eligibility

Table 1 – Structured search strategy carried out inMEDLINE/PubMed database. a

Search Topic and terms#4 Search #1 AND #2 AND #3#3 Composite resin:

“composite resins”[MeSH Terms] OR “resins, composite”OR (“composite”[All Fields] AND “resins”[All Fields]) OR“composite resins”[All Fields] OR (“composite”[All Fields]AND “resin”[All Fields]) OR “composite resin”[All Fields]

#2 Anterior teeth/Restoration:((“front”[All Fields] OR “anterior”[All Fields]) AND(“tooth”[MeSH Terms] OR “tooth”[All Fields] OR “teeth”[AllFields])) OR “Dental Veneers” [MeSH Terms] OR “DentalVeneers” [All Fields] OR “Veneer, Dental” [All Fields] OR“Veneers, Dental” [All Fields] OR “Dental Laminates” [AllFields] OR “Dental Laminate” [All Fields] OR “Laminate,Dental” [All Fields] OR “Laminates, Dental” [All Fields] OR“Dental Veneer”[All Fields] OR “Class III” [All Fields] OR“Class IV” [All Fields])

#1 Clinical trial/Longitudinal study/Retrospective study:((“clinical” [Title/Abstract] AND “trial” [Title/Abstract]) OR“clinical trials” [MeSH Terms] OR “clinical trial”[Publication Type] OR random*[Title/Abstract] OR “randomallocation”[MeSH Terms] OR “therapeutic use” [MeSHSubheading] OR “Longitudinal Studies”[MeSH Terms] OR“Longitudinal Studies” [All Fields] OR “LongitudinalStudy” [All Fields] OR “Studies, Longitudinal” [All Fields]OR “Study, Longitudinal” [All Fields] OR “LongitudinalSurvey” [All Fields] OR “Longitudinal Surveys” [All Fields]OR “Survey, Longitudinal” [All Fields] OR “Surveys,Longitudinal” [All Fields] OR “RetrospectiveStudies”[MeSH Terms] OR “Studies, Retrospective” [AllFields] OR “Study, Retrospective” [All Fields] OR“Retrospective Study” [All Fields] OR “Clinical Evaluation”[All Fields] OR “Follow-up” [All Fields])

a Searches in Scopus and Cochrane were adapted according to the

database.

criteria were included in the study and processed for dataextraction, while reasons for exclusion were recorded. In allsteps, lists were compared between the reviewers; in case of disagreement, nal decisions on inclusion or exclusion weremade following discussion with an experienced researcher(F.F.D.).

2.4. Data extraction

Data from selected full-text papers were independentlyextracted by the two reviewers. Data collection was done ongeneral study information, intervention characteristics, andlongevity outcomes (AFR, survival rate or success rate, andfactors associated with restoration failure). For studies thatpresented results in survival or success rate, the AFR werecalculated according to the formula: (1 − y)z = (1− x), in which‘ y’ expresses the mean AFR and ‘ x’ the total failure rate at ‘ z’years [10]. Data were divided in three groups according to typeof restoration assessed. For two reports from the same group

[17,18], data were collected and included in the table togetherbecause the studies had thesame sample and follow-up time,only differing in the clinical outcome assessed for the samerestorations.

2.5. Data analysis

High heterogeneity was observed among the selected studiesregarding study design, methods, and outcomes. Therefore, ameta-analysis was not considered appropriate and a qualita-tive synthesis was performed for the data collected.

3. Results

The ow diagram of the systematic review is shown in Fig. 1.From the initial 2273 studies identied after removal of dupli-cates, 41 full-text articles were assessed for eligibility and 17studies were included in thequalitative analysis.Theincludedstudies evaluated the clinical performance of Class III and/orClass IV restorations (10 studies), which were placed dueto caries, fracture, or replaced old restorations; veneers andfull-coverage restorations placed for aesthetic reasons (vestudies); andrestorationsplaced inwornteeth(twostudies).Intotal, 1821restorationswere evaluated andthefailure ratewas24.1%(439restorations), without taking intoconsideration thefollow-up times.

Table 2 shows all studies included in the systematic reviewand the variables collected. Included studies were publishedbetween 1996 and 2013, and the follow-up times varied fromthree to 17 years, with six articles reporting follow-up periodsover 10 years. Most studies were carried out prospectively, inEuropean dental schools, with multiple operators placing therestorations.Dental students were operators in onlyonestudy[4]. The number of restorations in each study varied from 25to 341, with most studies including less than 100 restorations.Only 7 studies were restricted to the evaluation of anteriordirect restorations. A modied version of the United StatesPublic Health Service (USPHS) criteria [19] was the criteriamost often used to evaluate restorations; three studies used

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P l eas ec i t et h i s ar t i c l ei npr es s as : Demar c oF F ,et al .Ant er i or c ompos i t er es t or at i ons : As ys t emat i c r evi ewonl ong-t er ms ur vi val and r eas ons

Table 2 – Longitudinal clinical studies with at least three years of follow-up evaluating anterior composite restorations: the systematic review results.

Author, Year Country Servicetype/

Operators/Study

design 1

Follow-uptime (years)

Patients/Number of

restorations

Restorationtype 2

Composite 3 Successrate/AFR4

Restorations in worn teethAl-Khayatt et al.,2013 [33]

England/UK Dental hospital/Multi/PL

7 15/85 Build-ups Herculite XRV 85%/2.3%

Smales andBerekally, 2007[39]

Australia Dental hospital/Multi/RL

10 * /164 125 (Class IV)39 (Build-up)

* 74.4%/3%

Restorations for aesthetic reasonsGresnigt et al.,2012 [14]

Netherlands University/Multi/PL

4 23/96 VENEERS/Reanatomization

Enamel PlusHFO, Miris2

87.5%/3.2%

Peumans et al.,1997 [17,18]

Belgium Private clinic/Single/PL

5 23/87 Veneers/Diastemas

Herculite XRV 82.8%/3.7%

Frese et al., 2013[40]

Germany Dental hospital/Multi/RL

5 58/176 Veneers/Diastemas

Enamel PlusHFO, Artemis,HerculiteXRV, EsthetX

84.6%/3.2%†

Alonso et al.,2012 [31]

Spain Private clinic/Single/RL

11 13/21 Veneers/Reanatomization

TPHSpectrum,HerculiteXRV, FiltekA110

75.2%/2.6%

Restorations due to caries, fractures, and replaced restorationsErmis et al., 2010[22]

Turkey University/Single/PL

3 30/80 Class III Clearl AP-X No failures

de Moura et al.,

2011 [4]

Brazil University/

Multi/RL

3 * /170 134 (Class III)

36 (Class IV)

TPH

Spectrum

91.8%/2.8%

(Class III)77.8%/8.0%(Class IV)

Deliperi, 2008[21]

Italy * /* /PL 5 20/25 Class III/Class IV

Vitalescence No failures

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Table 2 – ( Continued )

Author, Year Country Servicetype/

Operators/Study

design 1

Follow-uptime (years)

Patients/Number of

restorations

Restorationtype 2

Composite 3 Successrate/AFR4

van Dijken, 1999[41]

Sweden * /Multi/PL 5 52/149 Class III/Class IV

Pekall PLT 96%/0.8%

Spinas, 2004 [23] Italy University/ * /PL 7 * /70 Class IV† * 100% failure

Millar et al., 1997[42]

England/UK Researchinstitute/Multi/PL

8 * /28 25 (Class III)3 (Class IV)

Opalux 85.7%/1.9%

Kubo et al., 2011[25]

Japan University/Single/RL

10 58/147 Class III Clearl AP-X 81.5%/2%

van Dijken andPallesen, 2010[30]

Sweden * /* /PL 14 * /43 Class IV Pekall PLT 74.4%/2.1%

Smales andHawthorne, 1996[24]

Australia Private clinic/Multi/RL

15 * /341 284 (Class III)57 (Class IV)

* 53.4%/4.1%

Baldissera et al.,2013 [6]

Brazil Private clinic/Single/RL

17 55/219 168 (Class III)51 (Class IV)

Charisma,Herculite XRV

89.9%/0.6%

∗ Data not informed in the study.1 RL: Retrospective longitudinal; PL: Prospective longitudinal.2 † Traumatized tooth.3 All composites tested were microhybrids except for Filtek A110 (microll).4 †† Included 8 posterior composite restorations.5 a – Considered as failures: restoration lost or fractured, caries, tooth fractured, endodontic complication, and tooth extracted.b – Considered as failures: aesthetic criteria (color match, anatomical form, and surface roughness) [17], marginal adaptation and caries [18].c – Considered as failures: restoration fractured, endodontic complication, and tooth extracted.

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Table 3 – Reasons for failure of anterior composite restorations reported in the included studies. Number of failures (% of total restorations evaluated).

Fracture of tooth or

restoration

Caries Endodonticcomplication

Restorationloss

Marginaladaptation

Color Anatfo

Restorations in worn teethAl-Khayatt et al., 2013 [33]Smales and Berekally, 2007 [39] 28 (17.7) 2 (1.2) 2 (1.2) 14 (8.5) – –

Restorations for aesthetic reasonsGresnigt et al., 2012 [14] 5 (5.2) – – 6 (6.3) – 1 (1.0) Peumans et al., 1997 [17,18] – – - – 4 (4.6) 2 (2.3) 9Frese et al., 2013 [40] 20 (11.4) 3 (1.7) – 2 (1.1) – Alonso et al., 2012 [31] 1 (4.8) – – – – – –

Restorations due to caries, fractures, and replaced restorationsde Moura et al., 2011 [4]a 7 (4.1) – – 15 (8.8) – – – van Dijken, 1999 [41] 4 (2.7) 3 (2.0) – – – 1 (0.7) Spinas, 2004 [23]Millar et al., 1997 [42]Kubo et al. 2011 [25]van Dijken and Pallesen, 2010 [30] 11 (25.6) – – – – – – Smales and Hawthorne, 1996 [24]Baldissera et al., 2013 [6] 5 (2.3) – – – 2 (0.9) 5 (2.3)

Studies that did not report specic reasons for failure were not included in the table [21,23,42].a Reasons for failure of Class III and Class IV restorations were inserted together.

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to AFRs around 0.5% and 1%. This is in line with the results of the present study showing AFRs varying between 0 and 4%.

Regarding the method used to evaluate the restorations,most studies included here used the modied USPHS method[27], which enables a standardized and detailed evaluation of restorationsovertime.TheUSPHS method is oftenused inclin-ical studies but many researchers have developed their ownmodications for the method. The 12 studies included in thisreview that used the USPHS method ( Table 3) reported that a“modied” version of the criteria was used, hindering com-parisons among studies. The FDI method was more recentlydeveloped [28]in order to solve some limitations of the USPHSmethod, until then the most accurate method to detect differ-ences among restorative materials and techniques. However,as it was introduced in 2007, only two of the studies includedhave used the FDI criteria. Three studies used criteria denedby the authors, which might be useful for their own purposebut compromise comparisons among studies.

The review paper by Heintze et al. [26] was able to com-pare the level of criteria as it only included studies that wereusing these criteria. In the present review we were not ableto do the same; in contrast we included studies limited tolight-cured anterior composites andstudies on a more diversegroup of patients. Therefore, the two reviews offer a view onthe performance of anterior restorations from two differentperspectives. The overall results of our study showed thatanterior restorations had a good clinical performance, withlow AFRs and moderate to high success rates in thelong-term.The AFRs observed in the studies varied from 0 to 4.1%, whicharesimilar toAFRsobservedfor posteriorrestorations [11]. Thereview byHeintze etal. [26]concluded thatAFRs were between0.5% and 1%, which are lower compared to the AFRs observedfor posterior restorations according to a review done by thesame researchers on posterior teeth [29]. Thus it might bethat survival of anterior composite restorations is, on average,slightly better than posterior composites.

In another recent meta-analysis, the authors observed thatafter ve years of follow-up, the AFR of posterior compositeswas 1.8% and after 10 years the AFR increased to 2.4% [10].If we consider only the studies between three and nine yearsof follow-up in our review, the AFRs ranged from 0 to 3.7%,while for those studies with over 10 years of follow-up theAFRs were between 0.6% and 4.1%. This could be an indica-tion foran increasing failure rate over time,whichis explainedby increased marginal staining and discoloration reducing esthetical appearance. Moreover, as in the posterior restora-tions, secondary caries is only appearing as a relevant reasonfor failure after several years of service. Also, if we considerthe success rate among all included studies, it varied frommoderate (53.4%) to high (100%), except for the study whereall restorations failed. This diversity in results also indicatesthe different study types in which anterior restorations wereplaced. The 100% success rate was achieved in a study limitedin sample size, with restorations placed in selected patientsby one dentist; the 100% failures resulted from restorationsin emergency situations due to traumas, with endodonticcomplications leading to failures. These ndings highlightthat operator, patient factors, and the reason why restora-tions areplaced maydiffer considerablyin anteriorrestorationstudies.

As in most clinical studies, the reason for restoration fail-ureis often reported, but thereason why the initial restorationwas placed is almost never mentioned. One can speculatethat patients enrolled in prospective clinical trials are oftenmotivated and have low caries risk, thus the reason for place-ment of a restoration would be more related to estheticdemands. The most obvious reason for failures in anteriorrestorations are directly or indirectly related to the estheticappearance of a tooth or restoration ( Table3),while secondarycaries is seldom the reason for replacement and endodon-tic complications are limited. However, patients with cariesin anterior teeth are typically high-risk patients; therefore,trials of anterior restorations placed due to caries might beconsidered more challenging than trials of posterior restora-tions due to the environment in whichthe materials arebeing tested. Although a direct comparison between anterior andposterior teeth is not possible, the impression is there thatanterior restorations behave differently: restoration loss ismore present than in posterior teeth and esthetic appearanceplays an obvious role in the desire of the patient to have arestoration replaced.

The most reported cause of restoration failure in theincluded studies was fracture of the tooth or restoration. Inanterior teeth, Class IV restorations involving the incisal edgeare subjected to high masticatory loads, with fracture as apossible clinical outcome over time [4,6]. In the review byHeintze et al. [26], Class IV restorations had a twice as highfailure rate than Class III restorations. The lack of mechan-ical retention in most Class IV restorations may lead to agreater challenge to the tooth-restoration bonded interface.van Dijken and Pallesen [30] found a higher prevalence of failure in Class IV restorations performedwith differentmate-rials in bruxers, indicating thatoverloadingin individualswithocclusal disturbances mayincreasethe mechanical stresses inthe restorations, making them more prone to fracture. Whenthe authors followed the 13 restorations repaired after failure,they observed 10 (77%) new failures, all of them occurring inbruxers.

Failures more related to aesthetics were observed in stud-ies with build-ups or veneers as restorations, where coloralterations, surface staining, and marginal mismatch couldnegatively inuence the patient’s perception of the restora-tion [31]. Whereas secondary caries is considered a majorreason for failure in posterior composite restorations togetherwith fracture [10,11], results of the present review indi-cate that secondary caries is not a major cause for failureof anterior restorations. Caries is more prevalent in pos-terior than anterior teeth, and secondary caries lesions inposterior teeth are mainly located at the cervical wall of restorations, an area that is not easy accessible for clean-ing. Additionally, posterior teeth are subjected to higherloading, which may play a role in secondary caries develop-ment [32]. Generally, it seems that anterior restorations havea different failure behavior compared to posterior restora-tions. Caries and consequently secondary caries are lesspresent in anterior teeth, thus anterior restorations are likelymore prone to replacement due to esthetic demands, traumafracture, and loss of retention, which is explainable fromthe different functional properties of anterior and posteriorteeth.

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Few of the included studies actually addressed patientsand operators related factors associated with restoration fail-ure. In one study that evaluated build-ups placed in wornteeth [33], it was shown that restorations that took longerto place had higher chance to fail after seven years. Theauthors suggested that the association could be a result of those restorations being placed under more challenging clini-cal conditions, such as when moisture control was difcult toachieve, which would likely compromise their performance.Another study [25]reported that failures were associated withselective enamel etching before use of a self-etch adhesive,which is in contrast with a 8-year follow-up trial indicating that this bonding technique has a minor but positive effect onthe clinical longevity of restorations [34]. The authors them-selves [25] attributed the signicant differences to the factthat 58% of the failed restorations from that adhesive tech-nique were placed in a same individual, classied as high-riskpatient. The same study [25] reported that patients who hadplaced three or more restorations during the last three yearsshowed higher risk for failure, which corroborates the nd-ings of studies indicating that restorations placed in high-riskpatients might have poorer clinical performance [9].

Regarding the composite resins tested, the study with thelongest follow-up (17 years) was the only to detect differencesbetween materials [6], with a composite with lower mechani-cal properties exhibiting three times higher chance of failurethan a composite with higher ller content and higher elasticmodulus. Also in themeta-analysis byHeintze et al. [26], morehighly-lled hybrid composites showed better performance.In the present review, almost all included studies tested onlymicrohybrids, which are considered the gold-standard mate-rials for posterior restorations [11]. This opens the questionwhether the advances in ller technology in composites foranterior teeth observed in the last decade could improve thelongevityof anterior restorations.Having in mindthatfailuresdueto optical qualitiesof restorations(color andsurface stain)were only seldom reported ( Table 3), it seems that the newmaterials available in the market may have similar clinicalperformance in anterior teeth as compared to the traditionalmicrohybrids. This is corroborated by a recent systematicreview showing that the more recently introduced submicronand nanoll composites have not shown superiority in pol-ishability and retention of smoothness and gloss in vitro ascompared to microhybrids [35].

The literature on clinical longevity of posterior compositerestorationsis extensive andhas indicateda number of factorsthat could be associated with restoration failures, including socioeconomic level of the patient [15], type of dental serviceused [15], risk for caries or occlusal stresses [9], and opera-tor who performed the restoration [36]. Although one mightexpectthat thesame factors could affectthe longevity of ante-rior restorations, none of the studies included in this reviewwas able to observe similar associations. For anterior restora-tions, the environment of the patient and practice is perhapsdetermining the necessity of reinterventions in larger extentthan for posterior restorations. It is possible that practicesspecialized in esthetic and cosmetic dentistry, for instance,might have a higher turnover of replacement rate of anteriorrestorations for aesthetic reasons than general practices, butthese results are not available. The perception of aesthetics

itself may vary among individuals according to their age, edu-cational level, and environment to which they are exposed,and are probably determinant for reinterventions in anteriorrestorations in the everyday practice. A challenge for futureclinical studies is to reveal the relationship between these fac-tors related to dentistsand patientswithrestoration longevity.

Randomized clinical trials are the outstanding design toproduce scientic evidence regarding the efcacy of a treat-ment [37]. However, they may not be feasible for long-termfollow-ups or when a large number of patients should beenrolled in the study, because increased drop-out rates maybecome a problem, the cost of the study may be too high, andcounting on a trained andcalibrated dental team is notalwayspossible [38]. To overcome these shortcomings, practice-basedresearch studies have appeared in the literature; these stud-ies might be considered closer to the “real world” dentistrycompared to randomized clinical trials, and usually evaluateretrospectively the outcomes of different treatments [9]. Inour review, nine included studies were prospective and eightwere retrospectivestudies. Another limitationpresent in mostof the studies is the limited sample size, with some studiesenrollingveryfewpatientsand a smallnumberof restorations.The lack of appropriate sample size is a common mistake inclinical trials in dentistry and this lack of power may hideresults that actually are present. It should be pointed out,however, that the purpose of most clinical studies includedin this review was to look at the potential of test materials,not efcacy in general use.

One important shortcoming observed in all studies wasrelated to data analysis. The restoration was considered theunit of analysis, neglecting the fact that the restorationswhere placed in patients. This fact is critical when more thanone restoration is evaluated in a same individual, althoughcommonplace in studies on the clinical evaluation of restora-tions, because the analysis in a single level (considering therestoration alone) might generate misleading results. Strate-gies considering data organization in different levels (toothand patient) such as multilevelmodels or Cox-regression withsharedfrailtyhave been recentlyused inorderto overcome theproblems related to single level analyses [5,7,15], but to dateonly few studies have employed those methods. Therefore, itseemsthat althoughtheclinicalperformance of compositesinanterior teeth could be considered good, there is still room forwell-designed clinical trials, prospective randomized, as wellas prospective pragmatic trials designed in a practice-basedenvironment to evaluate the longevity of anterior compositerestorations and investigate factors associated with restora-tion failure.

5. Conclusion

Findings of the present review generally indicate a good clin-ical performance in the long-term (follow-up 3+ years) foranterior composite resin restorations, with annual failurerates varying from 0 to 4.1%. It seems that failure behaviorin anterior restorations is different from posterior teeth, withless secondary caries present and more restorations being replaced for other reasons such as esthetic appearance. How-ever, there is still room for well-designed clinical trials to

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evaluate the longevity of anterior composite restorations andinvestigate the specic factors associated with failure.

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[8] Da Rosa Rodolpho PA, Donassollo TA, Cenci MS, LoguércioAD, Moraes RR, Bronkhorst EM, et al. 22-Year clinicalevaluation of the performance of two posterior compositeswith different ller characteristics. Dent Mater2011;27:955–63.

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